How Breast Surgery Killed A Florida Teen

[NRSKarenRN]

interesting discussion. liked to hear our members thoughts.

[color=#5757a6]how breast surgery killed a florida teen

...what we know, so far, is that the 18-year old florida patient developed the very rare complication of general anesthesia, malignant hyperthermia, literally "dangerous [color=#006699]elevated temperature". .

...ga is the predominant choice of anesthesia cosmetic surgery, so her surgeon was within the ‘standard of practice' in that choice – expedience over outcomes.

unfortunately, ga or the ‘standard of practice' includes many unnecessary, avoidable and potentially fatal risks to patients choosing to have surgery that has no medical reason or indication.

among those avoidable risks are mh, blood clots to the lungs, airway mishaps leading to lack of oxygen to the patient's brain, postoperative nausea and vomiting (ponv), and postoperative cognitive disorder (pocd).

all of these risks can and should be avoided by having surgeons and patients choose a kinder, gentler anesthetic technique – propofol ketamine or minimally invasive anesthesia (mia)⮠pioneered by friedberg.

neither propofol nor ketamine are triggering agents for mh. had ms. kubela received mia, she would likely be alive today. bis monitoring of the patient's brain gives a numerical value of propofol sedation at which ketamine can be given without negative side effects...

teen dies after breast augmentation surgery - health news story ...

[airrn]

"Inhalational general anesthesia is not typically administered by a surgeon....usually in an office setting, this type of anesthetic involves a CRNA. Non-inhalational anesthetics usually do not trigger MH.

If there was a CRNA, what steps were performed to reduce the damage once recognized ?"

Once again that is your pertinent quote in it's entirety. You are the one who made the claim CRNA's are usually the only ones in an office therefore the burden of proof lies with you. Did you already forget about the recent NJ ruling regarding office base anesthesia?

I have taught ACLS to several MDA's who practice in the office setting. Irregardless does it matter what percentage of CRNA vs MDA practices in the office setting? Even if there are only a few MDA's you could not safely ASSUME it was a CRNA and this was PROVEN by the fact your assumption turned out to be FALSE.

"Accuracy in the ability to read is an important attribute of a CRNA."

Telling the truth is even a more important attribute. Obviously you and your ASA brothers and sisters are more concerned with trying to protect your profession. Even if this means dishonesty or in your case specifically, a double standard. Once again where is your statement, "If there was a CRNA or an MDA, what steps were performed to reduce the damage once recognized?" We are patiently waiting.

[03snakecrna]

Paindoc:

Understanding what you read and hear is an important attribute to being a DOCTOR. I guess we overlook the fact that there are really no seperate text books for MDA or CRNA. I studied from medical text in my crna training! I guess they read differently for you doctors. Its really a funny thing that it is always the mds that attack the crna. get a life. why are you on this board? pain doc. MDA or paindoc in this case= doctor doing nurses job wanting doctor pay!

thanks. have a nice day

[NRSKarenRN, BSN, RN]

welcome to samba - the society for ambulatory anesthesia

the society has grown to over 2000 members

http://www.sambahq.org/about-us/history.html

[stanman1968]

Whoa, slow down everybody. I am certainly no defender of the MD only anesthesia model, nor am a MD anesthesia defender let us keep our comments on point and try not to be so offensive M'kay? Other wise we will start looking like the SDN, not a good comparison I assure you.

In my opinion as long as Paindoc wants to post and comment he should I may not agree with his opinion, but I do not want to live in an echo chamber either.

[paindoc]

My experience shows CRNAs are more likely to be involved in office anesthesia than MDs but perhaps this is a regional difference. A series of calls to surgeons I know that perform office procedures revealed the following:

4 give versed via RN in their office

4 utilize CRNAs for procedures (mainly plastic surgery)

1 uses a MDA

It is likely somewhere within the organization of CRNA$ that there are statistics being expounded that CRNA$ provide 2/3 or more of all office anesthetics, just as they make the same assertion for anesthesia throughout the US. Perhaps we should check inside the CRNA$' little black bag they take with them to the surgeon's offices.....I am sure the CRNA$ carry their own stock of dantrolene given that the surgeon's offices do not typically stock dantrolene. Or if they do not carry dantrolene with them, why would they jeopardize patient lives by giving an anesthetic without having dantrolene immediately available?

[wtbcrna, MSN, DNP, CRNA]

My experience shows CRNAs are more likely to be involved in office anesthesia than MDs but perhaps this is a regional difference. A series of calls to surgeons I know that perform office procedures revealed the following:

4 give versed via RN in their office

4 utilize CRNAs for procedures (mainly plastic surgery)

1 uses a MDA

It is likely somewhere within the organization of CRNA$ that there are statistics being expounded that CRNA$ provide 2/3 or more of all office anesthetics, just as they make the same assertion for anesthesia throughout the US. Perhaps we should check inside the CRNA$' little black bag they take with them to the surgeon's offices.....I am sure the CRNA$ carry their own stock of dantrolene given that the surgeon's offices do not typically stock dantrolene. Or if they do not carry dantrolene with them, why would they jeopardize patient lives by giving an anesthetic without having dantrolene immediately available?

Paindoc,

I agree that it is more common for CRNAs to provide office based anesthesia. One of the best places to look for ancetdotal evidence of which provider works where the most is to just look on http://www.gaswork.com.

The simple fact is that if a provider is going to use MH triggering agents then they should stock the full 36 vials of dantrolene. There is no excuse in this country not to stock the full 36 vials of dantrolene. It doesn't matter if it is CRNA or an MDA the standards of care are the same.

By the way if CRNA=$ then an MDA=$$$

[jwk]

My experience shows CRNAs are more likely to be involved in office anesthesia than MDs but perhaps this is a regional difference. A series of calls to surgeons I know that perform office procedures revealed the following:

4 give versed via RN in their office

4 utilize CRNAs for procedures (mainly plastic surgery)

1 uses a MDA

It is likely somewhere within the organization of CRNA$ that there are statistics being expounded that CRNA$ provide 2/3 or more of all office anesthetics, just as they make the same assertion for anesthesia throughout the US. Perhaps we should check inside the CRNA$' little black bag they take with them to the surgeon's offices.....I am sure the CRNA$ carry their own stock of dantrolene given that the surgeon's offices do not typically stock dantrolene. Or if they do not carry dantrolene with them, why would they jeopardize patient lives by giving an anesthetic without having dantrolene immediately available?

Wow - n=8. No wait, n=5, because RN's giving versed in an office is NOT anesthesia. So by your own poorly designed and completed study, 20% of office anesthesia is administered by an anesthesiologist, and 80% by CRNA's.

[paindoc]

In determining whether dantrolene should be stocked, perhaps it would be advantageous to examine a risk analysis based on the specific agents used. For example, propofol has now been proven not to trigger MH unless the amounts given are 100 fold greater than those used in clinical practice. (Anaesth Intensive Care. 2007 Dec;35(6):894-8.). Similarly, midazolam was found to have no effect on MH susceptible tissues (Can Anaesth Soc J. 1984 Jul;31(4):377-81. Effects of midazolam on directly stimulated muscle biopsies from control and malignant hyperthermia positive patients.). Based on rabbit studies, opiates, lidocaine, and non-depolarizing muscle relaxants were demonstrated not to trigger calcium release, and were therefore deemed safe, while ketamine and SCH were potentiators of calcium release and therefore were not safe in MH. (J Anesth. 1989 Mar 1;3(1):1-9. Effects of anesthetic and related agents on calcium-induced calcium release from sarcoplasmic reticulum isolated from rabbit skeletal muscle.) Inhalational agents have almost uniformly demonstrated activation of MH.

Therefore, in an office setting in which no inhalational agents, SCH, or ketamine are to be used, one may conclude based on clinical experiential evidence and basic science studies that MH will not be induced by other available agents used in MAC or general anesthesia. Propofol, midazolam, lidocaine, and opiates are not triggering agents, therefore dantrolene should not be necessary to have immediately available during the use of these agents to induce amnesia/analgesia/anesthesia. In cases where SCH, ketamine, or inhalational agents are employed, dantrolene should be stocked and immediately available as a standard of care.

[wtbcrna, MSN, DNP, CRNA]

In determining whether dantrolene should be stocked, perhaps it would be advantageous to examine a risk analysis based on the specific agents used. For example, propofol has now been proven not to trigger MH unless the amounts given are 100 fold greater than those used in clinical practice. (Anaesth Intensive Care. 2007 Dec;35(6):894-8.). Similarly, midazolam was found to have no effect on MH susceptible tissues (Can Anaesth Soc J. 1984 Jul;31(4):377-81. Effects of midazolam on directly stimulated muscle biopsies from control and malignant hyperthermia positive patients.). Based on rabbit studies, opiates, lidocaine, and non-depolarizing muscle relaxants were demonstrated not to trigger calcium release, and were therefore deemed safe, while ketamine and SCH were potentiators of calcium release and therefore were not safe in MH. (J Anesth. 1989 Mar 1;3(1):1-9. Effects of anesthetic and related agents on calcium-induced calcium release from sarcoplasmic reticulum isolated from rabbit skeletal muscle.) Inhalational agents have almost uniformly demonstrated activation of MH.

Therefore, in an office setting in which no inhalational agents, SCH, or ketamine are to be used, one may conclude based on clinical experiential evidence and basic science studies that MH will not be induced by other available agents used in MAC or general anesthesia. Propofol, midazolam, lidocaine, and opiates are not triggering agents, therefore dantrolene should not be necessary to have immediately available during the use of these agents to induce amnesia/analgesia/anesthesia. In cases where SCH, ketamine, or inhalational agents are employed, dantrolene should be stocked and immediately available as a standard of care.

Interesting I can find no references to ketamine being a triggering agent in any of my books or notes. Ketamine is actually listed as a safe agent. I checked Clinical Anesthisology 4th ed, Nagelhout 3rd ed, and my notes from Dr. Sheila Muldoon one the head researchers in MH/head of the MH testing center at USUHS.

Malignant Hyperthermia Trigger and Safe Anesthetic Agents (from Dr. Muldoon)

Trigger Agents

Inhaled Anesthetics

Halothane

Isoflurane

Enflurane

Sevoflurane

Desflurane

Muscle Relaxants

Depolarizing (succinylcholine)

Intravenous Anesthetics

None

Safe Agents

Inhaled Anesthetics

N2O

Xenon

Intravenous Anesthetics

Barbiturates

Propofol

Ketamine

Muscle Relaxants

Nondepolarizing (all)

Local Anesthetics

All

Narcotics

Benzodiazepines

[deepz]

.......propofol has now been proven not to trigger MH ... (Anaesth Intensive Care. 2007 Dec;35(6):894-8.).....

A single study, while indicative, does not constitute 'proof' of anything per se.

[paindoc]

Proof is defined by both basic science and clinical science. There are many papers in the clincal realm that specify propofol does not trigger MH. The basic science paper proves what the clinical science cannot due to lack of sufficient numbers enrolled in clinical trials. Evidence based medicine is a process in which proof is offered through examination of ALL literature, levels I-V NASS or Cochrane levels A-D or one of many other systems. All literature is evaluated, then those with the highest scientific merit are given deference over others. In this realms, the proponderance of evidence is that there is unequivocal proof propofol does not trigger MH. The basic science study is but one of many, but demonstrates through the process of EBM (or in the case of CRNAs, I suppose it would technically be called EBN), how basic science (sorely lacking in the AANA Journal) can provide definitive evidence.

With ketamine, there is conflicting evidence, in far more definitive sources than the level V "opinion" of some professor (level V evidence is completely discounted by most EBM systems when there is more definitive evidence available) . One of the negative association papers is Masui. 1998 Nov;47(11):1296-301. [Effect of ketamine on the Ca(2+)-related functions of skinned skeletal muscle fibers from the guinea pigs]. Nevertheless, the overall level of evidence based on clinical studies for ketamine falls into the inconclusive category due to a lack of studies being published on the subject by CRNAs and anesthesiologists. (Why have you guys not published any studies on this?)

[foraneman]

It is likely somewhere within the organization of CRNA$ that there are statistics being expounded that CRNA$ provide 2/3 or more of all office anesthetics, just as they make the same assertion for anesthesia throughout the US. Perhaps we should check inside the CRNA$' little black bag they take with them to the surgeon's offices.....I am sure the CRNA$ carry their own stock of dantrolene given that the surgeon's offices do not typically stock dantrolene. Or if they do not carry dantrolene with them, why would they jeopardize patient lives by giving an anesthetic without having dantrolene immediately available?

You began your comments in this thread by assuming a CRNA had failed to properly care for a patient. You were wrong. You proposed that MDA practice in surgeon's offices was a rarity. You were wrong. Now, you resort to childish rhetoric and symbolism (CRNA$) which again singles out CRNAs and makes assumptions and accusations which are based on nothing other than your personal bias. You have NO idea what occurs in office surgery centers thruought the country and you frankly do not care. Your interest lies in attacking the practice of CRNAs whenever possible, regardless of facts or scientific basis. Your credibility, as such is nil. Falsus in uno, falsus in omnibus.